- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,757.66 / $1,757.66 / $1,757.66
| Facility | | $1,757.66 | $1,757.66 | $1,757.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $832.03 / $1,757.66 / $1,757.66
| Professional | | $832.03 | $1,757.66 | $1,757.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,450.50 / $1,450.50 / $1,450.50
| Professional | | $1,450.50 | $1,450.50 | $1,450.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,212.63 / $1,212.63 / $1,874.55
| Facility | | $1,212.63 | $1,212.63 | $1,874.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $885.22 / $1,212.63 / $1,641.43
| Professional | | $885.22 | $1,212.63 | $1,641.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $572.20 / $898.93 / $1,292.91
| Professional | | $572.20 | $898.93 | $1,292.91 |